Category: HIV/AIDS

According to leaked information about UNAIDS Executive Director Michel Sidibe’s correspondence with McKinsey and Company, 2018 will mark the beginning of the end of UNAIDS: the embattled leader has hatched a plot to begin dismantling the agency as soon as this year, writes Paula Donovan.

It’s no secret that the 2018 international AIDS conference this week in

Amsterdam is Michel Sidibe’s last with UNAIDS. His second and final term as

Michel Sidibé. Credit:Wikimedia

Executive Director is officially due to end in January 2020. But according to leaked information about his correspondence with McKinsey and Company, 2018 will also mark the beginning of the end of UNAIDS: the embattled leader has hatched a plot to begin dismantling the agency as soon as this year.

Many people may never have heard of the influential United States-based management consulting firm McKinsey until the company brought itself into disrepute by bilking the South African government of R1.028 billion through an illegal contract with the public utility Eskom. When caught, McKinsey apologized and did penance by repaying some of the funds. But that scandal may never have come to light if South Africa were not a sophisticated democracy, with a Constitution that guarantees the right of access to information “to everyone when that information is required for the exercise or protection of any rights.”

The United Nations is uniquely different. For anyone seeking truth from the United Nations, there is no right to freedom of information. Just the opposite: UN immunity gives the Organisation the right to withhold records and information, releasing them only at the Secretary-General’s discretion. From the deadly cholera epidemic in Haiti, to the sexual assault of children and women in the Central African Republic, to impunity for abuse of authority and sexual harassment enjoyed since the 1940s by countless, mostly male officials throughout the UN system, leaks can be the only hope of justice where freedom of information is denied.

Am I positively sure that what I’m divulging here is 100 per cent accurate? No. Does my experience with UN leaks cause me to believe that this particular information is true? Yes. And do I think that it’s worth taking the risk, given the likelihood that history will repeat itself, that the UN will deny all accusations, that Member States will have no “appetite” to investigate, that there will be ample time to destroy any evidence, and ultimately, that proof may be impossible to authenticate? Yes, it’s worth it; change doesn’t happen unless we take risks.

The distressing leaked information begins with advice given to Michel Sidibe by McKinsey and a very few, very high-level UN officials in New York, just after an internal WHO investigation closed a case of alleged sexual assault made against then-UNAIDS Deputy Executive Director Luiz Loures, and a claim against Sidibe himself, who was accused of interfering and trying to halt the ongoing investigation. The UN officials involved in dispensing advice were none other than Deputy Secretary-General Amina Mohammed and Jan Beagle. Ms Beagle served alongside Sidibe’s dear friend and accused serial sex abuser Luiz Loures as the second Deputy Executive Director of UNAIDS. While she herself was under investigation for harassing staff at UNAIDS, she was promoted by the Secretary-General to the top management and human resource position in the UN system. Not long after, United Nations Secretary General Antonio Gutteres chose her to lead the UN’s task force on—you guessed it—sexual harassment. All three UN officials are savvy enough to use private email accounts that can’t be tracked by UN investigators.

The transcripts of investigators’ interviews in the Loures case and the final reports had been sent to the Code Blue campaign, and under the pressure we caused by exposing the whole process for the sham that it was, the Secretary-General announced his intention to re-open the case — after Loures retired, and without asking the claimant if she wanted to start all over again. She doesn’t.

I share the view that the UN’s internal, hidden “judicial” processes are haphazard, unprofessional, and firmly biased in favor of the accused. For instance, WHO Director-General Tedros, whose investigators did such an appalling job the first time around, has been given the role of judge in round two. In the leaked correspondence, Sidibe asks the Deputy SG to keep him updated about the re-opened investigation. She says yes, I’ll phone you this evening, and he reassures her that he’s spoken with Tedros, who’s in the loop.

As hopeless as it seems, even one future UN leader might behave differently if 0105, the Office of Internal Oversight Services, were to ask just a few questions about the damage-control collusion among Sidibe, McKinsey, and UN headquarters. But will 010S ever ask senior UN officials why they used private email accounts to discuss highly sensitive UN business, knowing that only UN emails can be inspected by 010S? Will Under-Secretary-General for Management Jan Beagle be questioned about her advice to Michel (whom he addresses as “my dear sister”) that he clear the house? Will investigators ever dig into McKinsey’s concurrence—”I agree with Jan”—and their guidance that the problem with a Guardian newspaper partial exposé of the Loures case was “not how to remove the external perception but how to manage your reputation and the impact of the news on you”? Will the Deputy-Secretary-General be asked by 0105 whether, in reference to plans for an expert panel, she’d ever have said to Sidibe, “I would suggest that we make the recommendations of the commission look like they will achieve the way forward” if she’d been using her official UN email? Will anyone be asked how much the UN is paying for advice from McKinsey such as, “Michel, if everything stays as it is, please do not expose yourself further and let the dust settle, including with the SG,” or who prompted Mr Gutteres to play his part by announcing, months ago now, that the Loures case would be reopened — never to be mentioned again?

The leaks jump several weeks ahead to that plan to shut down UNAIDS, which Mr. Sidibe devised with McKinsey for the Secretary-General’s approval, via Amina Mohammed. They show that while he was threatening staff that they must unite behind him and mobilize women living with HIV to do the same, or else UNAIDS would come crashing down, he was simultaneously carving out a role for himself as grand marshal of the demolition. The plan: slash 40 per cent of UNAIDS staff, shovel the remainder into a newly designed “global public health” unit located somewhere within the UN, and —the cherry on top for wealthy, fatigued donor governments — end the AIDS exceptionalism that UNAIDS has championed vocally for over a decade. (After such a cold-blooded betrayal, can tears work again to persuade loyalists that it’s all the fault of others?)

The scheme has Sidibe heading up the “transition” with the aid of an external management consulting firm. McKinsey seems the obvious candidate. And as noted, without leaks, the protective shield of immunity allows the UN to hide the expense of the company’s exorbitantly priced advice. I wish I were surprised by the UN’s lack of concern about the role their crisis-management gurus played in the Eskom scandal in South Africa, or about the public exposure that forced McKinsey to end its $20 million contract with the federal US Immigration and Customs Enforcement agency, ICE, which is now famous for separating undocumented families crossing the US-Mexico border and locking up their children. In words reminiscent of the UN’s mantra of “zero tolerance for sexual exploitation and abuse,” the company’s Managing Director promised staff that the firm won’t do any more work that “advances or assists policies that are at odds with our values.” McKinsey and UNAIDS may be a perfect match.

It seems that at this point, there are two possible scenarios in play: perhaps UNAIDS and McKinsey consider it a triumph to have waged the world’s single most expensive and far-reaching damage-control campaign ever attempted by one man to discredit the MeToo movement. The student faithfully followed his coaches’ strategies: stay busy; phrase any apology as “if anyone misunderstood or was offended” in order to remain fully in charge; travel the world, whatever the cost, cooking up awards to give out as magnets to draw important people into your personal photographer’s range; meet, greet, and tweet about your one-on-ones with as many world leaders as humanly possible (and in a pinch, tweeting a selfie of yourself with a photo of Queen Elizabeth is second-best); terrorize staff into believing that if the captain goes down, the ship goes with it. At the Amsterdam AIDS conference, scatter employees throughout your audience who’ll jump to their feet and start the applause as soon as their leader takes the stage. Don’t worry unduly about Member States; they don’t want or expect change. As Amina Mohammed knows, the Programme Coordinating Board will be satisfied with a low-energy “review” culminating in easily implemented recommendations, all drawn up by UNAIDS in advance: a survey, a hotline, a series of meetings (same script, different titles: town halls, focus groups, civil society consultations…), a series of posters, a voluntary compact, and a pledge to redouble your efforts to ensure zero tolerance. Of course, two times zero is often the simplest “way forward.”

If one possibility is that McKinsey is declaring Sidibe victorious, another is that the Secretary-General struck a grand bargain: he may have offered a guarantee that he’d offer his full support without a shred of evidence if Sidibe would just devise a “game-changing solution” for the SG’s funding woes. They may have come to a gentleman’s agreement that if sacrificing the UN’s joint programme on AIDS is what it will take to show the US a leaner budget, well, you win some, you lose some.

As reasonable people, we should probably all be depressed about what these leaks reveal, and about the near-certain knowledge that like so many revelations before them, they’ll be repudiated and then ignored. But for the first time since we launched our Code Blue Campaign to end impunity for sexual abuse by UN personnel, we can see women (feminists, that is; not female replicas of the most ruthless male leaders) all over the world calling the shots where sexual conduct is concerned. So I’m actually feeling hopeful. The UN thinks that it’s beating the MeToo movement, but they’re always a generation behind. Everyone else’s day of reckoning is arriving; the UN’s day will come. – The views expressed in this opinion piece are the author’s own and not that of Spotlight or the Daily Maverick.

On 24 July, UNAIDS sent the following response via email:

Your article of July 22 on UNAIDS is based on false and fabricated

information. The UNAIDS leadership has not engaged in any

consultations with Mckinsey or United Nations senior staff on the

future of UNAIDS. The value of UNAIDS is clear. The dedicated staff of

UNAIDS are our greatest asset. We have unfinished business as

demonstrated by our recent report “Miles to go”. Together with our

partners, we are focused on delivering on our goals.

Yours sincerely,

Sophie Barton-Knott

Communications Manager

Paula Donovan is Co-Director of AIDS-Free World and its Code Blue Campaign. Donovan has served as senior advisor to the UN Special Envoy for HIV/AIDS in Africa from 2003 to 2006. Between 2000 and 2003, she was posted in Nairobi as UNICEF regional advisor on HIV/AIDS for eastern and southern Africa, and then as UNIFEM’s Africa-wide gender and AIDS advisor. Donovan worked for UNICEF at its international headquarters throughout the 1990s; she started her work in international relations as director of communications at the US Committee for UNICEF in the late 1980s. Donovan was the first to call for a UN agency devoted to women. UN Women was ultimately established in 2011. Among her accomplishments with AIDS-Free World, Paula Donovan forced the World Health Organization to re-examine the connection between contraceptive injections and the transmission of HIV; forced UNICEF to abandon a dangerous and ill-conceived HIV scheme called “The Mother-Baby Pack”; successfully demanded UNAIDS, WHO, and UNICEF stop the use of single-dose Nevirapine; championed the quest for justice for Zimbabwean women raped during the elections of 2008; joined the fight to overcome child marriage by making it an issue of child labour; and initiated and led the campaign of eliminating immunity for sexual violence committed by UN peacekeeping personnel. Donovan co-direct AIDS-Free World with Stephen Lewis.

Editorial note: The views expressed in this article are that of Donovan and does not necessarily reflect the views of Spotlight. The editors of Spotlight are conscious of the seriousness of the allegations made in this article. We are also conscious of the risks taken by those who leaked documents and the need to protect whistle-blowers. While we are not in a position to verify all allegations made in this article, we nevertheless consider the allegations to be credible and the publication of these allegations to be in the public interest. Should Mr Sidibe wish to submit a response to these allegations, we undertake to publish his response on Spotlight.

On Tuesday 24 July, the results from the extension to the PARTNER study were presented by Alison Rodger at a press conference at AIDS 2018, ahead of the main conference presentation. [1, 2]

After eight years the study was unable to find a single linked HIV transmission when viral load was undetectable, even after 783 couples had sex without condoms 77,000 times.

The results show that ART is as effective for gay men at preventing HIV transmission as it is for heterosexuals. They actually provide an even greater level of evidence for gay men as the first PARTNER results provided for heterosexual couples in 2014.

PARTNER extended to include more gay couples

The second phase of the PARTNER study included some participants from the first phase (which started in 2010) but was expanded from 2014 to 2018 to just enrol gay men.

PARTNER 2 included 972 gay couples where one partner was HIV positive and on effective treatment (ART) and one partner was HIV negative. Before joining the study, couples were already not using condoms. Participants also completed routine confidential questionnaires on their sex life.

To be included in the analysis, only periods when couples had sex without condoms (and without PEP or PrEP) were included, and when the positive partner had undetectable viral load (defined as being less than 200 copies/mL).

Overall, this led to data from 783 couples contributing 1596 couple years of follow up (CYFU). The main reasons for follow-up time not being included in the analysis (477 CYFU), was not having sex without condoms during that period (33%), use of PrEP or PEP (24%) viral load not available (18%) or other missing data. Less than 5% (only ~25 CYFU) were due to viral load being >200 copies/mL.

Median age was 43 (IQR: 31-46) and couples had already been having sex without condoms for a median of 1.0 years (IQR: 0.4 to 2.9). The positive partners had been on ART for a median of 4.0 years (IQR: 2.0 to 9.0), with high adherence (98% participants took >90% of meds), and 93% self-reported having an undetectable viral load.

Result: zero linked HIV transmissions after having sex 77,000 times without condoms

During median 1.6 years of follow-up (IQR: 0.9 to 2.9), couples had sex without condoms about once a week. The average (median) was 43 times a year (IQR: 19 to 74). And during the study this added up to almost 77,000 times.

Many of these couples were in open relationships and 37% of the HIV negative partners reported having other sexual partners. During follow-up, 24% of the negative partners and 27% of the positive partners reported at least one STI.

Over eight years, 15 HIV negative partners did become HIV positive. Importantly, all the new infections were with HIV that was structurally too different to be linked to their main partner. Phylogenetic analysis compared was the pol region of HIV in 15/15 paired cases and for env region in 13/15, with differences that were sufficiently distinct to rule out linked transmissions.

Range of theoretical risk – allowing for chance

An important aspect of the PARTNER study was to quantify risk. So even when no transmissions occurred, the study also reported an upper range of risk that might be possible, given that data is always limited. This is the 95% confidence interval (95%CI).

The initial PARTNER study produced an upper 95%CI of 0.46/100 CYFU overall, which is equivalent to a worst case of a couple needing to have sex for about 200 years for a transmission to occur. This is the highest level – in reality, this would be more likely to take thousands of years. Because two-thirds of participants were heterosexual, this figure was higher for gay men at 0.84/100 CYFU.

The new results from PARTNER2 are able to reduce the upper 95%CI to 0.23/100 CYFU for overall risk in gay couples: equivalent to a worst case when a couple would need to have sex for 400 years – if the true risk is at the upper 95%CI level.

The 95%CI was calculated using the 77,000 times that couples had sex without condoms. As this is a factor of number of CYFU, by definition, this figure becomes higher for sub-groups of risk. For example, the upper 95%CI for insertive anal sex was 0.27 (based on more than 52,000 times), 0.43 for receptive anal sex without ejaculation (>23,000 times), and 0.57 for receptive anal sex with ejaculation (based on 20,000 times). In the subgroup that included sex with a recent STI, the upper 95%CI was 2.9/100.

Note that these events add up to more than 77,000, as individuals could report more than one type of activity when they had sex.

Conclusion: PARTNER2 supports U=U

The PARTNER study was designed to provide a careful dataset that individuals could use as a basis for their own personal decisions. In doing this, even with extensive follow-up over eight years, the study has not been able to find a single case where HIV transmission occurred when viral load was undetectable (defined as less than 200 copies/mL).

The results provide the largest dataset to show how effectively HIV treatment prevents sexual HIV transmission. They support the U=U campaign that an undetectable viral load makes HIV untransmittable.

The research group have also produced a non-technical Q&A resource to cover additional questions. [3]

Note: this report has been published before the main conference presentation because of the IAS policy of choosing to hold press conferences before rather than after the researchers have presented their full results.

The report is based on early press access to the presentation slides. The embargo was lifted at the start of the related press conference but this report will be updated, if appropriate, after the full presentation.

Simon Collins is a community representative on the PARTNER study.

COMMENT

After eight years of trying to find a case of transmission with undetectable viral load, we have a dataset that covers both gay and straight sex – without a single linked transmission.

The PARTNER researchers should be acknowledged for extending the initial PARTNER study for another four years to produce an equitable level of confidence for gay men as for heterosexual couples.

Enrolling, following and retaining couples over eight years has been a considerable achievement. The complexity and the rigour of the phylogenetic analysis prove that none of the transmissions were linked.

As receptive anal sex carries a higher HIV risk than vaginal sex, these data can also reasonably be used to inform the risk from heterosexual anal sex.

This shows the risk of HIV transmission with an undetectable viral load to be effectively zero.

This week the price of bedaquiline in the public sector in South Africa was cut in half. What does this mean for the increased uptake of this critically important TB drug across the world?

This week at the International AIDS Conference South Africa’s Minister of Health Dr Aaron Motsoaledi announced that the South African government had negotiated a much-reduced price for the multi-drug resistant tuberculosis (MDR-TB) drug bedaquiline.

Bedaquiline is something of a break-through drug being one of only two new TB drugs approved in the last half-a-century. The South African government recently announced that bedaquiline will replace kanamycin injections in the country’s standard treatment for MDR-TB. This decision has been widely welcomed given the serious side-effects, such as irreversible hearing-loss, related to the painful injections. It is expected that the World Health Organization and other high-TB-burden countries will follow South Africa’s lead.

The new price announced by Minister Motsoaledi is $400 (around R5400) for a six-month treatment course. This is down from a price of $750 according to Motsoaledi. The figure quoted to Spotlight by the Department of Health last month was $820. Either way, the South African government has managed to negotiate a price drop of around 50%. For this they deserve credit.

More good news is that the new price will also be available to countries purchasing bedaquiline through the Global Drug Facility and to countries that benefited from the soon-to-end bedaquiline donation programme. It is now up to these countries to update their MDR-TB treatment guidelines and to ensure that all people who can benefit from the drug has access to it. So far, uptake of bedaquiline outside of South Africa has been depressingly poor and many people are still being exposed to hearing-loss causing injections of doubtful efficacy.

And yet, even the $400 price is far from ideal. Researchers from the University of Liverpool have estimated that bedaquline could be produced and sold at a profit for under $100. The researchers did however assume much larger volumes than current demand – so that price might not be realistic right away. It is with this in mind that activists recently demanded that bedaquiline should be priced no higher than $200 for a six-month course. Whether this demand played a role in the price-cut is not known.

For some perspective, a year’s supply of first line antiretrovirals costs the South African government about $100. Six months of drug susceptible TB treatment (a full course) costs less than $30. It should also be kept in mind that bedaquiline is just one of multiple drugs used for MDR-TB and the entire MDR-TB drug regimen will thus cost much more than $400.

It seems likely that for bedaquline to become available to all people who need it across the world the price will have to be dropped further. Then said, this week’s price-cuts is a firm step in the right direction. It is now up to countries to start scaling up use of this drug and over time to negotiate further price cuts.

Low is both an editor of Spotlight and a member of the Global TB Community Advisory Board, one of the organisations that demanded a reduction in the price of bedaquiline. The views expressed in this article are his own.

Hundreds of delegates walked out of the opening of the International AIDS Conference in Amsterdam last night in protest when UNAIDS Executive Director Michel Sidibe took the stage. By Kerry Cullinan, Health-e News Service

Before the walkout, a group of African women read out a statement describing Sidibe as “aider and abetter of sexual harassment” for his handling of a sexual assault case against his former deputy, Luiz Loures.

The women called for Sidibe to step down, then walked out, followed by a large number of delegates.

Before Sidibe took to the stage, the celebrity-studded opening event had focused on young people and people marginalized and at particular risk of HIV, including sex workers and injecting drug users.

Dutch Princess Mabel warned that, unless the real needs of girls and young women were addressed, “we could lose an entire generation to HIV”.

Focus on youth

Two 20-year-olds who were born with HIV, Mercy Ngulube and Ukranian Yana Panfilova, urged governments to do more to reach young people with sex education to protect them against HIV.

Professor Linda-Gail Bekker, AIDS 2018 International Chair and University of Cape Town scientist, said that HIV infections had increased by 30 % in Eastern Europe and Central Asia since 2010.

“They are the only region in the world to show an increase in HIV, largely because of injecting drug use,” said Bekker.

Actress Dame Elizabeth Taylor addressed the last AIDs conference held in Amsterdam 26 years ago, and last night her grandson, Quinn Tivey, and granddaughters Naomi and Laela Wilding continued the family tradition.

Tivey described the fight against HIV as a fight for human rights and social justice, while his cousin Naomi called for lesbian and gay rights to be recognized.

Dinah, a transgender sex worker activist living with HIV welcomed the 15,000 delegates to Amsterdam with a sober message: “Trans sex workers face exclusion, discrimination and violence and we have the highest rates of murder and suicide.”

Tedros Adhanom Gebreheyesus, Director General, World Health Organisation, warned that there are still too many people who cannot get HIV treatment as it is not available in their country, they can’t afford it or they can’t get access to it.

“We cannot be complacent about the end of HIV,” warned Tedros.

The conference, which lasts until Friday, will also be addressed by Prince Harry, Charlize Theron, Bill Clinton and Elton John. – Health-e News.

This is a statement read out by the group of 23 women as Michel Sidibe took to the stage at the opening plenary.

“…a political struggle that does not have women at the heart of it, above it, below it, and within it is not struggle at all.” – Arundhati Roy

We are the group of 23 women who dared to step into the light, to place ourselves at the heart of it, below it and within it. We dared to put pen to paper and say we will not keep quiet, that we will speak for those who have spoken and were silenced and for those who were too afraid to go public.

We have continued to speak out, we have met, written, consulted, spoken, begged, asked and spoken some more…everything we do is in solidarity with women, women who have for too long been forced to stay in the dark. We have stepped into the light.

We have been disappointed many, many times, but we have been in the struggle long enough to know this is a marathon, not a sprint and that victory is certain.

We feel strongly that there is a lack of respect, that individuals such as UNAIDS Chief Michel Sidibe, who has been an enabler and protector of sexual harassment, continues to be invited into women’s spaces, into spaces we occupy and fought hard to be in. That him being given platforms, is a secondary violation.

We hold no brief, we have no political ambitions, there is no monetary reward, we are simply a group of individual women who are speaking for ourselves, our daughters, our sisters, our mothers, our Comrades…who have for too long been silenced because we know we are up against a patriarchy machine which is well oiled and well-funded.

We refuse to hide behind structures and organisations to symbolically show other women we can show up for each other without asking for permission or a mandate.

We have been stripped of our dignity and power, but again we rise!

We do not ask for much:

We call on donors to continue supporting us and our struggle. We have heard too many stories of donors and those who sign the cheques using their power to bully and threaten those who dare challenge the power and position of people like Michel Sidibe.

We appeal to Michel Sidibe to step away from his scripted, spun, rehearsed propaganda machine and for once to look us in the eye and speak the truth. No more tears, let’s speak honestly and let’s make the difficult decisions.

Today we draw a panty line…not to be sensational, but because we have drawn a symbolic line in the sand. The panties symbolize the continuous violence against women and our struggles. They violate us daily, we continue to bleed.

We also note the information revealed by our sister at AIDS-Free World Paula Donovan, showing that we are up against a big, well paid machine. That we are the cannon fodder as big men and their women battle to cover their tracks. We will not be silenced, the AIDS struggle will not be sacrificed.

AIDS 2018 in Amsterdam will be remembered as a moment where women drew a line in the sand. It will be our #MeToo #UsToo moment.

We invite all allies of women, all believers that women rights are human rights to show your support at this conference, to add your voice. Each time you speak or present in a session, say one thing, beam it on the screen: “I Believe Her! Silence is violence! Time for change is now!”

Two years ago, we welcomed the world to the International AIDS Conference

Anele Yawa at the Durban2016 march

in Durban, South Africa. At a march of ten thousand people we held up banners proclaiming that 20 million people still need treatment. At that conference we said to the world that AIDS is not over – and indeed, the misguided rhetoric about the end of AIDS have now given way to more sober, more realistic assessments. The reality is that we are still in the thick of it.

In South Africa, as in many other countries, the first phase of the global AIDS response was a fight for policy. It was a fight for the idea that governments have a responsibility to do whatever they need to do to get HIV treatment to the people who need it. In our country it involved various court cases and a fight against AIDS denialism. Around the world it required a massive effort by activists, researchers, diplomats, progressive business persons and willing governments. Our shared success is something to be celebrated.

That said, the victories of this first phase of our struggle against HIV has to be won again and again. We cannot take the recognition of the human rights of all people for granted nor can we take the affordability of medicines for granted. As we hear reports of plans to shut down UNAIDS without any public consultation, we can’t take even United Nations support for granted. As we know too well, we can’t take continued political will or funding from our governments for the AIDS response for granted either. All this work from the first phase of the AIDS response must continue and we must support each other in it.

Almost everyone agrees today that we need to provide prevention, treatment and care to all who need it. The wide adoption of the 90-90-90 targets are testimony to that consensus. We have reached a point in the AIDS response where the question is not so much what to do, but rather how to actually get it done given the state of our healthcare systems.

We now know that policy victories and innovative technical interventions can only take us so far. In South Africa, and in many other countries, the AIDS response has come up against a wall. This wall is the widespread dysfunction in our healthcare systems. It doesn’t matter how good our donor-written policies are if they are never implemented. It is no use if we have medicines in depots, but the medicines never reach the people in the clinics. Beautiful guidelines for treatment and care mean little if we refuse to employ healthcare workers to actually provide the treatment and care.

As TAC we we are very clear: Our struggle against HIV is now in a new phase, a phase where our fundamental struggle is against dysfunction, mismanagement and corruption in our public healthcare system.

This new phase of our struggle is, in its way, much harder than the struggles against AIDS denialism and profiteering pharmaceutical companies. There are fewer victories to be had in laws or in policies. The problems we face are much more diffuse and harder to influence. Meetings in board rooms in Geneva, New York or Amsterdam matter less in this phase of our struggle, while community meetings in Lusikisiki and Khayelitsha matter more and more.

As TAC we have in recent years attempted to create accountability across the public healthcare system in South Africa. Our 200 branches spread across the country have each adopted a clinic – where our members, all users of the public healthcare system, both monitor and provide support where possible. Where issues persist, we escalate them to district or provincial level, and if needs be to the National Department of Health. Let me be clear, the more we monitor, and the more systematically we monitor, the more disturbed we get about the near collapse of our public healthcare system.

Our recent monitoring reports on seven of South Africa’s nine provinces paint a very bleak picture. In these and in our previous reports, it has become clear that TB infection control measures are grossly deficient in many facilities – turning many clinic waiting areas into likely transmission areas. Our diagnosis of widespread dysfunction in public sector facilities is confirmed by devastating reports from the Office of Health Standards Compliance (a statutory health inspection body that reports to parliament).

The crisis in many of our public facilities does not come from nowhere. Over the last decade, on the watch of former President Jacob Zuma, corruption has flourished in South Africa and the public service has been systematically hollowed out. This has directly impacted the healthcare system and the AIDS response.

It is worth recounting some details. Recently in emerged that millions ear-marked for HIV in the North West province was looted to pay overinflated prices to a controversial ambulance company that is now the subject of police investigations. This is while over 200 000 HIV treatment eligible people in that province are not yet on treatment.

In the same province strikes resulted in the shutdown of the public healthcare system, a shutdown that meant medicines distribution had stopped completely for weeks on end. Some shared treatment with others, others paid high prices in private pharmacies, many simply defaulted. These strikes, and a similarly disruptive strike at a Gauteng hospital, suggest that more healthcare workers are now prepared to strike in ways that place patients at risk. It tells us that the ethos of public service has dangerously eroded.

Of course, there are still many good people trying to do their best within a failing system. The tragedy though is that there is so little help for them. While some politicians come when there is a strike or a protest, they generally show little interest in fixing the underlying problems plaguing the system. Indeed, many officials in provincial departments of health have been appointed for political reasons or with corrupt motives and have neither the inclination or the ability to start turning the system around. And even with Jacob Zuma gone, the balance of powers in the ANC is such that many corrupt and underperforming persons remain firmly in place.

Part of why Cyril Ramaphosa is now President of South Africa is a deal he made with David Mabuza, the former Premier of Mpumalanga province and now Deputy President of South Africa. Mabuza has generally been associated with some of the more unsavoury characters in the ruling party and on his watch Mpumlanga politics was mired in alleged corruption. As Deputy President Mabuza is also now the new head of the South African National AIDS Council, a body already ridden in controversy over the way it removed its former CEO and its failure to deal decisively with conflicts of interest. While Premier in Mpumlanga and chairing that province’s provincial AIDS council, Mabuza failed completely to address that province’s severe HIV crisis, not to mention the general corruption of that province’s government.

That Mabuza is now making some of the right noises on HIV and TB is of course welcome and we will hold him to his words. That our government has finally approved a progressive new policy on patents and medicines 17 years after the Doha Declaration is also welcome. That our Department of Health has shown urgency in introducing new medicines such as bedaquiline for MDR-TB and dolutegravir for HIV is to be applauded.

But, as Minister Aaron Motsoaledi recently admitted, South Africa’s healthcare system is in crisis. From our national department he has tried to stop the crisis, but in South Africa the healthcare system is run by provinces and Motsoaledi has been powerless to get the provinces into line. The underlying reality is that inside the borders of South Africa, our internationally popular Minister is severely hamstrung by his lack of political power.

Ultimately, as with all the issues we faced in the first phase of our struggle, the second phase is also fundamentally political. And as we have to address the patronage networks within our ruling party in South Africa, we call on our international allies to address the distorted values of the current United States administration and to seek out again the international solidarity that made our movement as successful as it once was.

As the world gathers in Amsterdam for the 22nd International AIDS Conference, my appeal to you is to once again make AIDS political. Just like the gag rule and Global Fund withdrawal is political, the failure in my country to act against corrupt individuals is political. The potential shutdown of UNAIDS and the mishandling of sexual harassment at the agency is political. In recent years we have too often played nice with our elected leaders and as a result they have come to believe that AIDS is almost over. We must once again take the gloves off and make AIDS political. We have elected our leaders, we demand that they deliver the AIDS response and the healthcare systems we need.

Anele Yawa is the General Secretary of the Treatment Action Campaign. The TAC is a South African membership-based organisation that advocates for the rights and interests of people living with and affected by HIV and TB.

Almost everyone in the HIV world is talking about providing services to key populations – a ground-breaking project in Thailand is providing an example of how to go about it. They kindly answered Spotlight’s questions.

Q: What is the Tangerine project and how does it work?

A: The “Tangerine” Community Health Center is the first transgender-specific sexual health and wellbeing clinic in Thailand and in Asia. Launched in November 2015, Tangerine offers fee-based healthcare services that is situated in an Anonymous Clinic at the largest HIV testing facility in Bangkok at the Thai Red Cross AIDS Research Centre (TRCARC).

Q: What practical steps do you take to create a welcoming environment for trans people?

A: TRCARC conducted a series of transgender community consultations with diverse members of transgender communities, including transgender advocates, healthcare providers, those working within the fashion industry, as well as transgender sex workers. Through the extensive consultations, TRCARC understood the barriers and the unmet health needs. The consultations revealed that transgender people faced obstacles in accessing hormone level monitoring and treatment, the most basic health services that they regularly require to affirm their gender identity. The services available in general are not transgender-friendly, or even worse are provided outside the medical profession. Hormone treatment services were identified as the entry point to make the clinic attractive to its target populations. At the end of the consultation, the name “Tangerine”, the slogan “Where transition fulfils identities” and the logo were mutually adopted.

After the consultation, TRCARC Director Professor Praphan Phanuphak supported all healthcare staff to attend the training on “gender sensitization in healthcare settings” before providing direct services to transgender clients. This created the learning platform between healthcare providers and transgender communities. At the same time, the Tangerine protocol was developed by Dr. Frits van Griensven, which was adapted from international guidelines in order to make it appropriate within the local Thai context. This included hormone supplies, hormone therapy monitoring, and interpretation of laboratory results. Data collection forms were also designed to respond to gender identity, sexual orientation and sex assigned at birth.

Tangerine officially opened in late November 2015 and became the first clinic catering specifically to the needs of transgender people in Bangkok. Funding from the United States Agency for International Development (USAID) through the LINKAGES Thailand Project covered the costs of the community consultations, certain healthcare staff, communications, trainings and research studies conducted to specifically address sexual health concerns among transgender people.

Q: What positive outcomes have you seen?

A: From November 2015 to December 2017, there were 1 184 transgender individuals receiving services from Tangerine with 4 501 visits. Of those, 972 were transgender women (TGW) and 212 were transgender men (TGM). Of those TGW, median (IQR) age was 25.4 (22.5-30) years, 55% had education below bachelor’s degree, 25% were unemployed, 56% used alcohol, and 10% used amphetamine-type stimulants. The HIV testing rate among TGW was 91%, with 12% HIV prevalence. 80% were successfully initiated on antiretroviral therapy.

Recently, Tangerine has intensively utilized transgender influencers as an online-to-offline social media strategy to better reach transgender individuals at high risk for HIV infection, including those who are young and first-time HIV testers. From October 2017-January 2018, there were 247 (60%) transgender clients from online, out of 411 clients.

“Tangerine is the clinic that addressing my several health needs, including hormone treatment. The staff here were very friendly and knowledgeable. Having the HIV testing was no longer fearful for me.” Jiratchaya Sirimongkolnawin (Mo), Miss Tiffany’s Universe 2016 and Miss International Queen 2017

Q: What lessons have you learnt from the project?

A: Some lessons learned from Tangerine are:

Its strong foundation was built on meaningful participation of the transgender communities at the nascent stage.

The clinic’s transgender staff who are members of people living with HIV and who represent vulnerable community, have also proven essential to ensuring that the clinic continues to offer accessible, transgender-friendly services and remains in close contact with the needs of the community it serves.

Support to enhance knowledge exchange between the trans community and health professionals is necessary to increase access to and provision of transgender health services, aiming at ending AIDS in Thailand and the region.

The model that integrates gender affirmative hormone services and sexual health services is feasible and effective in increasing access to and retention in HIV testing and PrEP service uptake.

Available data from Tangerine increases visibility of transgender people in the National AIDS Program and will be further used for the development and refinement of a comprehensive health service package and policy advocacy for transgender people in Thailand.

Tangerine also provides technical assistance to community-based organizations – Sisters Foundation in Pattaya, Mplus Foundation in Chiang Mai, and Rainbow Sky Association of Thailand in Bangkok and Songkhla- in replicating the comprehensive health service model. The community health workers were trained on GAHT and hormone dispensing in different local settings.

Q: What advice could you give to people trying to set up similar projects in other places like e.g. South Africa?

A: In establishing a transgender health project, it is essential to engage transgender communities at the beginning including planning, implementation, and evaluation. This will help you understand their needs and truly respond to the needs of the populations you serve.

Substantial involvement from healthcare providers and leadership from your organization is also fundamental as it will be translated into policy, action and resources. The combination of transgender staff and cisgender staff will help create a learning platform in the healthcare environment and will build mutual trust between transgender communities and healthcare providers.

You may not need to have a full service package at the formation, but you will need to come up with a minimum service package, based on what the communities really need such as hormone counseling, hormone level measurement integrated with other sexual health and HIV services. You can start with a gender-responsive data collection form and gender sensitisation for healthcare team. The services can be integrated in different settings such as public health facilities, MSM-focused community-based organisations or standalone health centres, depending on resources, population size and sustainability.

Nosipho Soga is a 19-year-old learner who hails from Kuyasa, a Khayelitsha township in Cape Town. She can best be described as bubbly, intelligent, engaged and relatively small for her age. It is clear that she is used to people questioning her age, assuming that she is much, much younger. So much so that she carries her Identity Document with her everywhere she goes just to prove that she is above the age of 18.

Nosipho has seen many of her peers fall pregnant and contract Sexually Transmitted Infections and HIV. It is their experiences, as well as the high prevalence of HIV in this group that has fueled her activism. According to South Africa’s National Strategic Plan for HIV, TB and STIs 2017-2022 adolescent girls still face high rates of HIV making up 37% of new infections with around 100, 000 new infections a year[1].

It is such concerns that encouraged Nosipho to join the Treatment Action Campaign (TAC), a membership-based organisation that advocates for the rights and interests of people living with and affected by HIV and TB.

Nosipho’s work is centered around ensuring that adolescent girls understand sexual and reproductive health rights and make sure they access these services. TAC’s youth groups meet every Wednesday to engage on issues affecting them. These mainly relate to sugar daddies, and knowledge sharing in a context of very little sexuality education.

Nosipho argues that “sugar daddies that engage in inter-generational relationships are a big part of the problem”. She locates this in South Africa’s socio-economic problems, arguing that many young girls resort to such relationships in order to eke out a more dignified existence in a context of extreme poverty, inequality and unemployment. These relationships typically involve a older man with greater resources and power and a significantly younger woman with no financial resources or social capital. Such distorted power relations have left many young women susceptible to intimate partner violence and less able to negotiate safe sex.

Furthermore, the short-comings of the Department of Basic Education’s Life Orientation programmes in schools, according to her, also further accentuates the problem because it is foundational in nature and does not teach learners much more than they already know.

In many instances learners are unaware of the numerous ways they can protect themselves from HIV and STI infection, as well as from unwanted pregnancies, placing them at great risk, she says.

In 2016, the State introduced the ‘She Conquers’ programme, with the intention of ensuring more economic opportunities for adolescent girls; reducing gender-based violence; significantly reducing teen pregnancies and ensuring access to youth friendly sexual and reproductive health (SRH) services. However, many youths do not know about it, says Nosipho. “we do not have access to youth friendly sexual and reproductive health services because we feel like we cannot talk about sex and sexuality to nurses at the local clinics without being judged.”

This article is part of a Spotlight special series on people who form part of so-called key populations.

However, at the age of 31, she is as passionate as ever about the need to address the health issues of the youth, and adolescent girls in particular. She is a soft spoken and serious young woman. Drawing a smile from her is hard work. Almost as if she is constantly thinking about the problems at hand. As a Treatment Action Campaign (TAC) member, youth clinic health navigator and a sexual and reproductive health club facilitator, Nosicelo has extensive knowledge of her subject matter and speaks with a quiet passion in her native Xhosa.

Acknowledging the problems brought on by the lack of in depth information provided by the Life Orientation programmes in schools, specifically in Cape Town, Nosicelo and her team have worked tirelessly to speak to in-school youth about HIV and sexual and reproductive health rights and services. The fact that her team is also comprised of young people helps bridge the gap and make learners more open to speaking openly to them. However, this project operates on a small scale because of personnel and funding issues. “We speak to principals and School Governing Bodies about the nature of our work. Sometimes parents and SGBs find our work problematic because they think that we are promoting sexual relations between students, when we are addressing the realities of adolescent boys and girls.”

Nosipho says that “a lot of schools do not give us permission to speak to the learners. We currently speak to adolescents in 13 schools here in Khayelitsha. We only speak to secondary schools. We have very little time in which to speak to the adolescents as they have other commitments. We provide them with condoms and we make sexual reproductive health cool. We also speak to them about the dangers of concurrent partnerships.” Through her work, Nosipho has realized that adolescent boys are more willing to collect the condoms they provide, with an average of 60% of the condoms being collected by them.

They also speak openly about other impediments that make adolescent girls, at almost 2 000 new infections a week in South Africa a very high-risk group. As someone whose parents both died at an early age, leaving her in the care of an aunt with limited means, Nosicelo is aware of the appeal of sugar daddies, a trap she did not fall for, despite some of the seeming appeal. “Our workshops also focus on the issue of intergenerational relationships. I try make it as interactional as possible, with adolescent girls debating the issue between themselves. We try and instill the lesson that they need to be okay with what their lot in life is at that particular time and stress the need to strive to better themselves and their families in various ways, without resorting to sugar daddies.”

“Our greatest victory has been the creation of six clubs of adolescent girls. Over the years these clubs have had a steady membership, the members speak openly about the challenges they face and the members continue to be HIV negative as a result of responsible behavior. They also haven’t had STIs. If that were to change we would offer them critical support, but we sincerely hope not. The goal is to move up to ten groups within Khayelitsha.”

Finally, for Nosicelo, “as a key population as well, adolescent girls should be treated in the same way as sex workers. I strongly believe that PrEP should be readily available for (sexually active) people as young as 12, if we are to curb the scourge of HIV among the youth. Condoms are not enough…”

This article is part of a Spotlight special series on people who form part of so-called key populations.

Dressed in a Robert Sobukwe Dashiki and trendy shoes, Thando Jack draws

Thando Jackby Joyrene Kramer

gazes from the mainly white upper middle-class folk in Cape Town who can afford to be taking a stroll in the Company Gardens during a week day. They obviously try not to but there is something about him that captivates them.

When we start engaging, it becomes clear that it Is a genuine sense of love and concern about members of a community that embraced him that makes Thando do the work he does. It is alarming figures such as those released by UNAIDS that spur him on. According to UNAIDS, Men who have sex with Men (MSM) globally are a staggering 24 times more likely to be living with HIV than the general population[1]. A 2015 study in South Africa found that 33.9% of gay-identified men in a research sample of 378 black MSM in the historic township of Soweto were found to be HIV positive[2]. This is compounded by the finding that between 88% and 94% of MSM in South Africa were reported to not know their HIV status, in a context where high levels of concurrent sexual partners among the Soweto cohort, for instance, was reported by 73% of respondents[3].

It is these figures and his own lived experience as an MSM that led 28-year-old Thando Jack to becoming an activist since his late teens. His extreme passion for ensuring that MSM access affordable, quality health care services is clear from the moment he starts engaging.

Working as a data capturer at a prominent men’s health non-governmental organisation (NGO) in Cape Town, South Africa, Thando is at the coalface of clinical consultations focusing on ensuring that data involving HIV tests results, on the treatment programme, including the rate of defaulting, and on the outcomes of TB test results are meticulously captured. The organisation runs programmes in Cape Town and Johannesburg, as a result of the high MSM populations and the corresponding high risk of infections in these two cities.

Despite many gains, including a progressive Constitution and law reform that allows the LGBTI+ community to enjoy the same rights as heterosexual people, Thando is worried about numerous factors that continue to affect MSM’s access to healthcare services in South Africa, including stigma. “Many health workers are still not informed or sensitive about MSM issues when providing healthcare despite the numerous interventions of organisations such as Anova Health and Health4Men, who conduct sensitization trainings in health facilities across South Africa”, says Thando. “Just from engaging with a clinician in history taking and explaining how you got anal warts or Gonorrhea, you can see from the reaction that you are being discriminated against. It’s sad. You would hope that someone who has the courage to get out of bed to seek medical health care is not treated that way”, he says.

Sensitisation trainings occur for health practitioners in both public and private practice. The programme has a website that directs MSM to health practitioners who are MSM friendly. These are services that do involve greater awareness, tolerance of others and less stigmatization of health seekers on the basis of their sexual orientation. For Thando, it is imperative that programmes such as these are amplified to reach areas beyond just Johannesburg and Cape Town, as MSM in other areas will be better placed to seek health care services knowing they won’t face the discrimination they often still face. “There is still a need for more public and private health care workers to undergo this MSM sensitization training throughout the country, as only a certain portion have gone through this programme”, he says.

Ivan Toms clinic in Cape Town, which Thando highlights as an essential health care facility in improving the fight against HIV amongst MSM and the site from which they work has about 13 000 patients who leave their own communities and local clinics from areas as far flung as Paarl, Atlantis, Fish Hoek, Wellington, as well as nearby areas such as Khayelitsha, Phillipi, Gugulethu and Kraaifontein in order to access critical health care services from practitioners who are MSM friendly. They acknowledge the importance of the right to food through providing food and/or energy drinks to underweight patients in their road to health[4].

Having been born and raised in Gugulethu, and realizing the continued stigma faced by MSMs in his community when attempting to access healthcare, a critical worry of Thando’s is that safe spaces such as the health facility he works for will have to shut down their doors as a result of potential funding cuts from prominent international donor organisations. This could quite conceivably result in many defaulting and in an increase in avoidable deaths of many people, some of whom make up his close community.

The external stigma; continued fear of help seeking among men and the potential funding crisis form a deadly cocktail that would effectively place the gains made among MSM through the ‘universal test and treat’ policy[5] from the national Department of Health in jeopardy.

For Thando, “when it comes to the needs of the MSM population and significantly reducing the rate of infections, it is important to find innovative ways and systems to help in fighting HIV. We need to keep up with new technologies and knowledge to do so, something we aren’t really doing at the moment.”

This article is part of a Spotlight special series on people who form part of so-called key populations.

[1] UNAIDS (2017), “Blind Spot: Reaching out to Men and Boys – Addressing a Blind Spot in the Response to HIV”, PDF.